Provider Demographics
NPI:1316693765
Name:MADELINE ROSE MASTECTOMY BOUTIQUE, LLC
Entity type:Organization
Organization Name:MADELINE ROSE MASTECTOMY BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WALCK
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:607-296-2021
Mailing Address - Street 1:100 RANO BLVD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2776
Mailing Address - Country:US
Mailing Address - Phone:607-296-2021
Mailing Address - Fax:607-296-2023
Practice Address - Street 1:100 RANO BLVD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2776
Practice Address - Country:US
Practice Address - Phone:607-296-2021
Practice Address - Fax:607-296-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Single Specialty